The present invention relates generally to a system and method to optimize medical diagnosis, procedures and reimbursement claims using a structured search space.
The Health Care Finance Administration, hereinafter referred to as HCFA, is a government agency responsible for the operation of oversight of medical insurance programs such as Medicare and Medicaid. These programs handle medical claims submitted by health care providers, such as doctors, hospitals, and skilled nursing facilities and reimburse claims that are valid. In recent years, to stop intentional and unintentional overbilling, Medicare has implemented fraud control and medical necessity initiatives that place an enormous burden upon health care providers to avoid unintentional mis-billings.
Medicare billing is based on two sets of codes: the diagnosis code and the procedure code. The diagnosis code represents the diagnosed illness or malady or in some cases just the fact that the patient is having a routine checkup. The procedure code represents the procedure being ordered and is associated with the diagnosis code on the basis of medical necessity. In other words, each diagnosis code has a set of related procedures that can be ordered and will, barring any other mitigating circumstances, be reimbursed by Medicare. Procedure codes are reimbursed based upon a set fee schedule determined and set by HCFA. Procedure codes can represent a simple procedure or a compound procedure that represents multiple individual procedures. This allows for more than one procedure code sequence to represent the exact same set of procedures performed. One consequence of this is that one code combination will allow for a larger reimbursement than another code sequence for the same services performed.
As a result of the recent health care reform mentioned earlier, HCFA has specified that when determining proper coding for procedures any logic that groups payable procedures in a manner which yields the least expensive payment is acceptable. As a rule, duplicate procedures are not reimbursable. That is, the same health care provider cannot get reimbursed for performing the same procedure on the same patient more than once for a given encounter. Exceptions to this rule can be indicated in the reimbursement claim by adding a modifier code to the main procedure code which effectively makes it a completely new code.
There are two types of procedure codes that can be used by a health care provider to specify the procedures ordered. The first type are CPT (Common Procedural Terminology) codes that were developed by the American Medical Association (AMA). The second type are HCPCS (Health Care Procedural Coding System) codes that were developed by HCFA to address issues with the CPT codes as they relate to medical billing.
Therefore, what is needed is a system and method to assist in providing the health care professional assistance in selecting medical procedures for a given medical diagnosis. In addition, an optimization of the medical procedures prescribed for a particular medical encounter is also needed. Given the complexity of all of the possible medical procedures, a system and method that provides a medical professional with the least cost combination of the medical procedures ordered is also needed. In addition, the system has to follow the coding practices prescribed by Medicare.
The present invention addresses all the needs mentioned above. The present invention is a system and method that takes a given set of ordered medical procedure codes and constructs a search space representing all possible combinations of simple and compound procedures, which is then traversed in a systematic manner using an evaluation method for each node that determines the reimbursable value. The traversal continues through the entire search space until a node or graph is located that represents a procedure code combination reflecting the minimum reimbursement possible. The rest of the search space is then traversed and new combinations are compared to the current minimum combination. If a lower combination is found, the current minimum combination is then replaced. This process continues until the entire search space is traversed resulting in the lowest reimbursement combination that satisfies the set of the original ordered procedures.
The system and method can be implemented in a general purpose computer or a portable computer. One embodiment is implemented on a palm sized computer with the medical professional entering medical diagnosis and selecting medical procedures directly. The system would then optimize the ordered procedures for billing and patient encounter recording purposes.
In another embodiment, the attending medical professional records the medical diagnosis and ordered medical procedures and then another medical professional enters the information into a general purpose computer.
The system also has access or a direct connection to the patient""s information and/or medical history. The invention would be part of an all purpose medical diagnosis/procedure/billing system, or a standalone software package that finds the optimized billing for Medicare reimbursement from a listing of ordered medical procedures.
In addition, a system and method for optimizing medical diagnosis, procedures and reimbursement claims using a structured search space is described. The system may include: a master procedure list of alphanumeric codes that represent each of a plurality of medical procedures, wherein the master procedure list includes simple procedures and compound procedures which consist of at least two simple procedures; a value associated with each of the plurality of medical procedures; a list of ordered procedures listing medical procedures for a specific medical encounter; a search tree of all possible combinations of the simple procedures and the compound procedures in the list of ordered procedures; and a minimum total of the values associated with the medical procedures in the list of ordered procedures.